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Perinatal Substance Exposure: Challenges. Priya Jegatheesan, MD Balaji Govindaswami, MBBS, MPH Division of Neonatology, Santa Clara Valley Medical Center, San Jose. August 12 th , 2014. Objective. Scope of the problem of substance abuse Biology of addiction in adult vs. newborns

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Perinatal substance exposure challenges

Perinatal Substance Exposure: Challenges

Priya Jegatheesan, MD

Balaji Govindaswami, MBBS, MPH

Division of Neonatology,

Santa Clara Valley Medical Center, San Jose.

August 12th, 2014


Objective
Objective

  • Scope of the problem of substance abuse

  • Biology of addiction in adult vs. newborns

  • Challenges in the care of newborns exposed to substances in utero


Substance abuse global problem
Substance Abuse – Global Problem

  • Alcohol – causes 6% of global death

  • Drugs

    • 3.4-6.6% adults use drugs

    • 1 % of deaths attributable to drugs

http://www.unodc.org/documents/data-and-analysis/WDR2012/WDR_2012_web_small.pdf


Substance abuse national problem samhsa 2012
Substance Abuse – National Problem: SAMHSA 2012

  • 24 m (9%) used illicit substance in the last month

  • Most common is Marijuana – 7%

  • Methamphetamine 0.2-0.3%

  • Non-medically used prescription drugs 2.6%

  • Dependence – 8.5%

  • Pregnant women – 5.6% used illicit drugs (lower than in non-pregnant (10.7%) population; 15-17 y – 18%

    http://www.samhsa.gov/data/NSDUH/2012SummNatFindDetTables/NationalFindings/NSDUHresults2012.pdf


Maternal co morbidities
Maternal co-morbidities

  • Psychiatric illness

    • Depression, Anxiety disorders

    • 45% Axis 1 diagnosis, 75% Axis 2 diagnosis

  • PsychosocialLower socio-economic status & educational levelAdverse Childhood Experiences:

    Abuse – emotional, physical, sexual

    Dysfunctional household

    • Substance abuse

    • Mental illness

    • Domestic violence

    • Incarceration

    • separation


Maternal co morbidities1
Maternal co-morbidities

Infections – HIV, Hep B, Hep C

Transmission IV, blood products, sexual transmission

Risk FactorsIV drug useRisky sexual related behaviorRisky drug related behaviorImmunocompromised



Biology of addiction
Biology of Addiction

  • VTA – dopaminergic neurons tell the individual if the stimuli is rewarding or aversive

  • NA – GABAergic neurons mediate the rewarding effect

  • Amygdala – establishes conditioned learning, learns associations to environmental cues and the rewarding experience.

  • Hippocampus – establishes memory associated with reward experiences

  • Pre-frontal cortex – glutamatergic neurons controls the executive function that mediates drug seeking behavior.


Biology of withdrawal in newborns
Biology of Withdrawal in Newborns

Physical signs of withdrawal from opiates is mediated by Neuro Epinephrine

Neurons in Locus

Ceruleusin Mid Brain.

LC – Neurons have Mu receptors , Alpha 2 Adrenergic receptors that decrease NE via adenylcyclase – cAMP - PKA



Challenges in care
Challenges in Care

  • Universal Screening vs. Risk Based Scoring; Toxicology: Urine vs. Meconium vs. Cord vs. Hair

  • Score for Withdrawal - which score, when to score, how to score, when to treat

  • Treatment options only for opiate withdrawal: opiates vs. phenobarb vs. clonidine

  • Breastfeed or not

  • Discharge planning difficulties: home with mom or foster care


Screening for substance exposure
Screening for Substance Exposure

  • Universal Standardized questionnaire

    • Non-judgemental

    • Trauma informed care

    • 5Ps, … etc.

  • Toxicology

    • Urine

    • Meconium

    • Hair / Umbilical cord

  • Legal Implications

    • Consent

    • CPS referral


Withdrawal scores
Withdrawal Scores

  • Only for opiate withdrawal

  • Finnegan Score vs. Modified

  • Standardized, inter rater reliability – staff education

  • When to score – before or after feeds

  • Polysubstance abuse may impact the scores (nicotine withdrawal etc.) however it is used specifically to treat opiate withdrawal

  • Encourage Parental involvement

  • Optimize non-pharmacological measures


Medical treatment for nas
Medical treatment for NAS

  • Opiate agonist – Morphine / methadone acts on Mu receptors

  • Clonidine – Alpha 2 adrenergic agonist – suppresses noradrenergic mediated sympathomimetic symptoms of withdrawal

  • Phenobarbital - GABAergic agonist, but also blocks AMPA (excitatory) receptor, also non-specific to other receptors in brain

  • Ondansetron – 5HT antagonist – decreases the withdrawal symptoms in animals / adults


Breastfeeding
Breastfeeding

  • Uncertain pharmacokinetics of illicit drugs in mothers and newborns

  • Adulterants in the drugs

  • Variable excretion into breastmilk

  • Co-morbid psychiatric illness

  • Psychiatric medications

  • Viral infections that are contraindications (HIV, HSV with active lesions on the breast)



Challenges with breastfeeding
Challenges with breastfeeding

  • Complicated recommendations

  • Medical team often ineffective in making social assessments

  • Medical drugs vs. Illicit drugs

  • Marijuana – medical / non-medical

  • When in hospital, do you initiate breastfeeding and then evaluate, pump and dump, discourage ……..


Discharge planning
Discharge Planning

  • Difficult social situation, lack of a support system

  • Unstable / unsafe home environment

  • Lack of adequate residential treatment programs for mother and babies

  • Outpatient Perinatal Substance Abuse Programs

  • Foster care vs. discharge with biological mother with CPS supervision

  • Breastfeeding but at still at risk of relapse


Acknowledgement
Acknowledgement

  • Substance exposed mothers and newborns at SCMVC

  • SCVMC MCH Staff

  • Perinatal Substance Abuse Program at SC County

  • Santa Clara First Five

  • VMC Foundation

  • VON iNICQ Collaborative

  • NIH Funding for Prevention of NAS study

  • SAMHSA Advisory group – MAT NAS


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